Dravergonz’13 Dravergonz’2013 MEDICINE EXAM CASES N.DILIP JAIVANTH K.G.AJAEY Tirunelveli Medical College Dravergonz’13 1. CNS Cerebrovascular accident 2. CARDIOVASCULAR SYSTEM Mitral regurgitation Mitral stenosis Aortic regurgitation Aortic stenosis 3. RESPIRATORY SYSTEM Pleural effusion Fibrosis Collapse(atelectasis) Bronchiectasis 4. GIT Ascites with cirrhosis of liver Hepatomegaly Spleenomegaly Hepatospleenomegaly Dravergonz’13 1. CEREBROVASCULAR ACCIDENT Name: Mr.Arumugam Age: 54 yrs Sex: male Place: Kadayam Occupation: Farmer COMPLAINTS: Difficulty in using his ® upper and lower limb Deviation of angle of mouth to the left X 3 days X 3 days H/O PRESENTING ILLNESS: The patient was apparently normal before 3 days. He went to sleep normally. On the next day morning, at about 5 am, when he woke up, he found difficulty in using his ® upper and lower limb with deviation of angle of mouth to the left. The weakness is confined more to the upper limb. The weakness is sudden in onset, progressive and attained its peak 3 hrs after the onset. This episode is not accompanied with headache, vomiting, blurring of vision or loss of consciousness. He was immediately taken to the nearby PHC and was referred to TvMCH. The patient is now improving. Dravergonz’13 H/O difficulty in raising his ® upper limb above the head H/O difficulty in mixing the food(/ using the hand(left) for toilet purpose) H/O difficulty in getting up from squatting position H/O difficulty in holding the slippers No H/O difficulty in raising the head from the bed No H/O difficulty in turning the head from side to side No H/O difficulty in rolling over the bed No H/O disturbance in consciousness or orientation No H/O memory, speech, behavioural or emotional Motor system Higher functions Disturbances No H/O disturbance in appreciating smell No H/O blurring of vision or disturbance in appreciating colours No H/O drooping of lids, double vision or difficulty in moving the eye in all directions No H/O difficulty in appreciating sensation over the face or difficulty in chewing H/O deviation of angle of mouth to the left H/O stasis of food in the mouth and drooling of saliva No H/O hard of hearing, tinnitus or vertigo No H/O nasal regurgitation of food or nasal twang of voice No H/O difficulty in turning the head from side to side No H/O difficulty in rolling over the bed No H/O difficulty mixing the food or initiate swallowing Dravergonz’13 No H/O difficulty in appreciating the sensation of clothes No H/O difficulty in appreciating hot and cold Sensory system No H/O difficulty in appreciating pain No H/O tingling or numbness No H/O involuntary movements Cerebellar functions No H/O difficulty in reaching the objects No H/O difficulty in bringing food to the mouth No H/O difficulty in initiating micturition No H/O frequency, urgency or incomplete evacuation of bladder Autonomic function No H/O bowel disturbances No H/O injury to the head No H/O fever with neck stiffness Aetiological history No H/O chest pain or palpitation No H/O diarrhoea or ear discharge (Don’t ask for the history of recent vaccination as the anti-rabies vaccine derived from the sheep’s brain are not used now-a-days) PAST HISTORY No H/O similar complaints in the past No H/O Transient Ischaemic Attacks(TIA) or Reversible Ischaemic Neurological Deficits(RIND) No H/O diabetes, hypertension, tuberculosis, bronchial asthma or epilepsy No H/O STD exposure Dravergonz’13 No H/O any drug intake (In females ask for OCP intake) PERSONAL HISTORY: The patient is non-vegetarian Chronic smoker For the past 30 years Smokes 20 beedi/day(1 pack) Smoke years20X30600 Pack years1X3030 Chronic alcoholic for the past 30 years FAMILY HISTORY: No H/O similar complaints among family members SOCIOECONOMIC HISTORY: According to modified Kuppusamy scale, the patient belongs to CLASS 4(Upper lower socioeconomic class) Dravergonz’13 SUMMARY: A 54 year old male, a chronic smoker and an alcoholic, came with complaints of difficulty in using his ® upper and lower limb with deviation of angle of mouth to the left for the past 3 days. This episode is sudden in onset, progressive and is not accompanied by vomiting, headache, blurring of vision or loss of consciousness. This is a case of Cerebrovascular accident probably of thrombotic aetiology. GENERAL EXAMINATION The patient is, Conscious, communicative, co-operative Oriented Afebrile Moderately built and moderately nourished Not anaemic Not jaundiced No cyanosis No clubbing No pedal oedema No significant generalised lymphadenopathy Dravergonz’13 Markers: No markers of atherosclerosis No markers of syphilis No neurocutaneous markers VITALS: PULSE: Rate: 72/minute Rhythm: regular Volume: normal volume Character: no specific character No radio femoral delay No vessel wall thickening Felt equally in all peripheries CAROTIDS ARE FELT NORMALLY ON BOTH SIDES BLOOD PRESSURE: 130/90 mmHg Measured in the left upper limb with patient in supine position RESPIRATORY RATE: Rate: 18/minute Rhythm: regular Type: Abdomino-thoracic type TEMPERATURE: 37° C Dravergonz’13 EXAMINATION OF CNS 1.HIGHER FUNCTIONS: The patient is right handed Consciousness: normal Orientation to Time Place Normal person Behaviour: well behaving Memory recent Immediate Intact remote Speech spontaneous speech Comprehension Naming Normal Repitition Reading Word output Disarticulation of speech is present Sleep pattern: normal Dravergonz’13 Emotional status: normal No delusion, illusion or hallucination 2. CRANIAL NERVES: 1. CRANIAL NERVE Olfactory nerve RIGHT Able to perceive smell LEFT Able to perceive smell 2. Optic nerve 6/60 6/36 Visual acuity Colour vision normal normal Field of vision Light reflex 3,4,6 Oculomotor, trochlear, abducent nerve normal normal Ocular movement no drooping no drooping Drooping of lids present present Light reflex 5. Trigerminal nerve normal normal Sensation over the face normal power normal power Masseter and temporalis present present Corneal and conjuctival reflex Patient is able to open the mouth against resistance 7. Facial nerve UMN type of Right facial nerve palsy is present 8. Vestibulo-cochlear nerve Rinnie’s test Weber’s test positive Positive No lateralisation Dravergonz’13 9,10 11. Glossopharyngeal, vagus nerve Uvula is in midline ‘Ah’ test Normal elevation present Palatal/pharyngeal reflex Accessory spinal nerve Sternomastoid Able to shrug the shoulders against resistance Able to turn the face against resistance temporalis 12. Normal elevation present Hypoglossal nerve Able to protrude the tongue No deviation No fibrillation Power- normal 3. SPINOMOTOR SYSTEM: 1. BULK: RIGHT LEFT 32 33 23 24 LOWER LIMB THIGH 48 49 LEG 36 37 UPPER LIMB ARM FORE ARM No obvious wasting in the limbs Dravergonz’13 2. TONE: UPPER LIMB LOWER LIMB RIGHT Hypertonia of flexors Hypertonia of extensors LEFT Normal tone Normal tone 3. POWER: RIGHT LEFT UPPER LIMB Shoulder joint Adduction Abduction Flexion Extension Medial rotation Lateral rotation Elbow joint Flexion Extension Wrist joint Dorsiflexion Palmarflexion Hand grip 3 2 3 2 3 3 5 5 5 5 5 5 3 2 5 5 2 3 60% 5 5 100% 4 4 5 5 LOWER LIMB Hip joint Adduction Abduction Dravergonz’13 Flexion Extension Knee joint Flexion Extension ankle joint Dorsiflexion Plantarflexion 4 4 5 5 4 4 5 5 2 3 5 5 4.REFLEXES: 1.SUPERFICIAL REFLEXES Corneal Conjuctival Palatal Pharyngeal Abdominal Cremastric plantar 2.DEEP TENDON REFLEXES biceps triceps supinator knee jerk ankle jerk RIGHT LEFT Present Present Absent extensor Very brisk Brisk Brisk Very brisk Brisk ANKLE CLONUS is present. flexor Present Present Present Present present Dravergonz’13 4. CO-ORDINATION SYSTEM: RIGHT LEFT UPPER LIMB Finger to nose test Finger nose finger test Draw circle in air Unable to do because of weakness Able to do LOWER LIMB Heel knee test Draw circle in air Unable to do because of weakness Able to do 5. SENSORY SYSTEM Fine touch Crude touch Pressure Pain Temperature Vibration Proprioception Cortical sensation Tactile localisation Tactile discrimination Sterignosis graphesthesia RIGHT LEFT Normal normal Dravergonz’13 OTHER SYSTEM EXAMINATION: CVS: S1, S2 heard No added sounds No murmur RS: Normal vesicular breath sounds heard No added sounds GIT: Normal bowel sounds heard No oranomegaly No free fluid DIAGNOSIS: A case of Cerebrovascular accident with right sided hemiparesis involving the left sided internal capsule probably the lenticulostriate branch of left middle cerebral artery and the aetiology is probably thrombotic. Dravergonz’13 2. PLEURAL EFFUSION Name: Mr. Natraj Age: 46 years Sex: Male Place: Tirunelveli town Occupation: works in cotton mill COMPLAINTS: Cough Chest pain Difficulty in breathing X X X 15 days 15 days 10 days H/O PRESENTING ILLNESS: The patient was apparently normal before 15 days, after which he developed, CHIEF RESPIRATORY COMPLAINTS Cough 1. Cough with expectoration Duration: 15 days 2. Chest pain Onset: gradual, progressive 3. Breathlessness Type: dry 4. Haemoptysis 5. Wheeze Nature: intermittent Associated with chest pain Aggravated during inspiration No relieving factors No radiation, seasonal or positional variation Chest pain Site: confined to the right side Duration:15 days Dravergonz’13 Onset: gradual, progressive Type: pricking Nature: intermittent Aggravated during inspiration No relieving factors No radiation Difficulty in breathing Duration: 10 days Onset: gradual, progressive Grade 3 (MMRC grading) Nature: continuous Aggravated during walking No relieving factors No variability Not associated with orthopnoea or Paroxysmal Nocturnal dyspnoea No H/O haemoptysis No H/O wheeze No H/O abdominal pain abdominal distension leg swelling palpitation syncope No H/O Night sweats Evening rise in temperature For cardiovascular system For tuberculosis Dravergonz’13 No H/O Loss of weight Loss of appetite Hoarseness of voice Difficulty in swallowing For malignancy PAST HISTORY: No H/O similar complaints in the past No H/O diabetes, hypertension, tuberculosis, bronchial asthma or epilepsy No H/O aspiration PERSONAL HISTORY: The patient is non-vegetarian Chronic smoker For the past 30 years Smokes 20 beedi/day(1 pack) Smoke years20X30600 Pack years1X3030 Occasional alcoholic FAMILY HISTORY: No H/O similar complaints among family members Dravergonz’13 OCCUPATIONAL HISTORY: The patient works in a cotton mill. SOCIOECONOMIC HISTORY: According to modified Kuppusamy scale, the patient belongs to CLASS 4(Upper lower socioeconomic class) CONTACT HISTORY: No history of contact with tuberculosis patients SUMMARY: A 46 year old male, a chronic smoker, came with complaints of chest pain, cough and breathlessness for the past 15 days. The system involved is respiratory system. GENERAL EXAMINATION The patient is, Dyspnoeic at rest Conscious Oriented Afebrile Moderately built and moderately nourished Not anaemic Dravergonz’13 Not jaundiced No cyanosis No clubbing No pedal oedema No significant generalised lymphadenopathy Markers: No markers of Tuberculosis No markers of SVC obstruction No markers of carbon dioxide retention No markers of HIV No markers of Horners syndrome VITALS: PULSE: Rate: 84/minute Rhythm: regular Volume: normal volume Character: no specific character No radio femoral delay No vessel wall thickening Felt equally in all peripheries BLOOD PRESSURE: 130/90 mmHg Measured in the left upper limb with patient in supine position RESPIRATORY RATE: Rate: 26/minute Rhythm: regular Type: Abdomino-thoracic type Dravergonz’13 TEMPERATURE: 37° C EXAMINATION OF RS INSPECTION: Upper respiratory tract: Nasal mucosa- normal No nasal septal deviation No nasal polyps Oral cavity: Good oral hygiene No dental caries Respiratory system proper: Chest wall is bilaterally symmetrical and elliptical in shape No chest wall and spine abnormalities like, Kyphosis Scoliosis Pectus excavatum/ carinatum Trachea appears to be deviated to the left Apical impulse is not visible Rib space is widened on the Right side No drooping of shoulder Dravergonz’13 Movements APICAL ANTERIOR POSTERIOR RIGHT normal Diminished diminished LEFT Normal normal Normal No Supraclavicular fullness or hollowness No dilated veins, scars, sinuses or tapping marks PALPATION: Not warm Non tender Trachea is deviated to the left Apical impulse is felt in the left fifth intercostal space ½ inch lateral to the midclavicular line(shifted) Movements: APICAL ANTERIOR POSTERIOR RIGHT normal Diminished diminished LEFT Normal normal Normal Measurements: Inspiration 84 Expiration 81 Chest expansion 3 Hemi thorax measurement: Inspiration RIGHT Expiration Inspiration LEFT Expiration 42 41 42 39 Chest expansion=1 Chest expansion=3 Dravergonz’13 The movement is diminished on the right side Spinoscapular RIGHT 13 distance LEFT 13 No tactile fremitus Vocal fremitus: AREAS Supraclavicular Infraclavicular Mammary Axillary Infraaxillary Suprascapular Interscapular infrascapular RIGHT Normal reduced reduced reduced reduced Normal reduced reduced LEFT Normal Normal Normal Normal Normal Normal Normal Normal PERCUSSION: Direct percussion over the clavicle-resonant Kronig’s isthmus- resonant AREAS Supraclavicular Infraclavicular Mammary Axillary Infraaxillary Suprascapular Interscapular infrascapular RIGHT Resonant Stony dull Stony dull Stony dull Stony dull Resonant Stony dull Stony dull LEFT Resonant Resonant Resonant Resonant Resonant Resonant Resonant Resonant Dravergonz’13 Tidal percussion- dull(percuss traube’s space in left sided effusion) No straight line dullness No shifting dullness AUSCULTATION: AREAS Supraclavicular Infraclavicular Mammary Axillary Infraaxillary Suprascapular Interscapular infrascapular RIGHT NVBS Diminished Diminished Diminished Diminished NVBS Diminished Diminished LEFT NVBS NVBS NVBS NVBS NVBS NVBS NVBS NVBS RIGHT Normal reduced reduced reduced reduced Normal reduced reduced LEFT Normal Normal Normal Normal Normal Normal Normal Normal Vocal resonance: AREAS Supraclavicular Infraclavicular Mammary Axillary Infraaxillary Suprascapular Interscapular infrascapular Succession splash- absent Coin test- negative Dravergonz’13 OTHER SYSTEM EXAMINATION: CVS: S1, S2 heard No added sounds No murmur GIT: Normal bowel sounds heard No oranomegaly No free fluid CNS: No focal neurological deficit DIAGNOSIS: A case of Right sided pleural effusion probably due to tuberculous aetiology. Dravergonz’13 3. MITRAL REGURGITATION Name: Mr. Iyappan Age: 46 years Sex: Male Place: Palayamkottai Occupation: Shop keeper COMPLAINTS: Difficulty in breathing X 1 week H/O PRESENTING ILLNESS: The patient was apparently normal before 1 week, after which he developed, Difficulty in breathing Duration: 1 week CHIEF CARDIAC COMPLAINTS Onset: gradual, progressive 1. Chest pain Class 3 (NYHA Classification) 2. Palpitation Aggravated by exertion 3. Exertional dyspnoea 4. Syncope Relieved by rest 5. Easy fatigueability Associated with orthopnoea and Paroxysmal 6. Oedema Nocturnal dyspnoea H/O palpitation Duration: 5 days Dravergonz’13 Intermittent irregular Precipitated by exertion Relieved by rest No associated features(passing urine after an episode of palpitation indicates supraventricular tachycardia) No H/O Chest pain No H/O cough with expectoration No H/O syncope No H/O easy fatigueability No H/O abdominal pain abdominal distension Swelling of legs For Right heart failure No H/O fever For infective endocarditis No H/O Oligurea or puffiness of face For renal causes PAST HISTORY: H/O similar complaints before 4 years. He went to GH for the same and was diagnosed to have heart disease and was prescribed medications. No H/O diabetes, hypertension, tuberculosis, bronchial asthma or epilepsy. No history suggestive of rheumatic fever. Dravergonz’13 PERSONAL HISTORY: The patient is non-vegetarian Chronic smoker For the past 30 years Smokes 20 beedi/day(1 pack) Smoke years20X30600 Pack years1X3030 Occasional alcoholic FAMILY HISTORY: No H/O similar complaints among family members SOCIOECONOMIC HISTORY: According to modified Kuppusamy scale, the patient belongs to CLASS 4(Upper lower socioeconomic class) SUMMARY: A 46 year old male, a chronic smoker and an alcoholic, came with complaints of dyspnoea on exertion associated with orthopnoea and PND and palpitation for the past 1 week with similar complaints in the past. The system involved is cardiovascular system. Dravergonz’13 GENERAL EXAMINATION The patient is, Comfortable at rest Conscious Oriented Afebrile Moderately built and moderately nourished Not anaemic Not jaundiced No cyanosis No clubbing No pedal oedema No significant generalised lymphadenopathy Markers: No markers of Rheumatic heart disease No markers of Infective endocarditis No markers of congenital heart disease No markers of atherosclerosis No markers of syphilis VITALS: PULSE: Rate: 84/minute Rhythm: irregularly irregular Volume: variable volume Character: no specific character No radio femoral delay Dravergonz’13 No vessel wall thickening Felt equally in all peripheries Heart rate = 106 PULSE DEFICIT= 22 BLOOD PRESSURE: UPPER LIMB RIGHT LEFT LOWER LIMB RIGHT LEFT 103/90mmHg 130/90mmHg 140/96mmHg 140/96mmHg RESPIRATORY RATE: Rate: 18/minute Rhythm: regular Type: Abdomino-thoracic type TEMPERATURE: 37° C JVP: Not elevated EXAMINATION OF CARDIOVASCULAR SYSTEM INSPECTION: Chest wall is symmetrical No chest wall and spine abnormalities like Kyphosis, scoliosis, Pectus excavatum or carinatum Apical impulse is seen in more than one space Trachea appears to be in midline Dravergonz’13 No precordial bulge Parasternal lift is seen No visible pulsations No scars or dilated veins PALPATION: Not warm, not tender Apical impulse felt in left fifth intercostal space 1 cm lateral to the midclavicular line Hyperdynamic A thrill is palpable in the mitral area Parasternal heave is present- Grade 3 P2 is palpable in the pulmonary area Trachea is in midline AUSCULTATION: MITRAL AREA S1 – soft S2 – loud No added sounds A high pitched soft blowing pan systolic murmur of grade 4 is heard in the mitral area with diaphragm of the stethoscope with patient in the left lateral position with breath held in Dravergonz’13 expiration and the murmur is radiated to the axilla. TRICUSPID AREA S1 – soft S2 – heard No added sounds A transmitted systolic murmur is heard PULMONARY AREA S1 – soft S2 – loud P2 No added sounds No murmur AORTIC AREA S1, S2 heard No added sounds No murmur OTHER SYSTEM EXAMINATION: RS: Normal vesicular breath sounds heard Basal cripitations are heard GIT: Normal bowel sounds heard No oranomegaly No free fluid Dravergonz’13 CNS: No focal neurological deficit DIAGNOSIS: It is a case of acquired valvular heart disease, a regurgitant lesion of the mitral valve, with pulmonary hypertension probably of rheumatic aetiology. The patient is in atrial fibrillation (or sinus rhythm) with no signs of heart failure or infective endocarditis. Dravergonz’13 DESCRIPTION OF OTHER MURMURS Mitral stenosis: A low pitched rough rumbling mid-diastolic murmur of grade 3 or 4 (which follows opening snap) is heard in the mitral area with the bell of the stethoscope with patient in the left lateral position and breath held in expiration. Aortic stenosis: A high pitched crescendo-decrescendo murmur of grade 3 or 4 (which follows ejection click) is heard in the aortic area with the diaphragm of the stethoscope with patient leaning forward and breath held in expiration and the murmur is radiated to the carotids. Aortic regurgitation: A high pitched decrescendo murmur of grade 3 or 4 is heard in the second aortic (Erb’s) area with the diaphragm of the stethoscope with patient leaning forward and breath held in expiration. Dravergonz’13 3. ASCITES Name: Mr. Marimuthu Age: 48 years Sex: Male Place: Kadayam Occupation: Mason COMPLAINTS: Abdominal distension X 15 days H/O PRESENTING ILLNESS: The patient was apparently normal before 15 days, after which he developed, Abdominal distension Duration: 15 days Onset: gradual and progressive Uniform distension Not associated with pain H/O yellowish discoloration of eyes and passage of high colour urine Duration: 1 month Normal colour stools Not associated with itch No H/O abdominal pain No H/O vomiting H/O loss of weight and loss of appetite No H/O fever Dravergonz’13 No H/O vomiting of blood or passage of black colour stools For renal No H/O puffiness of face or Oligurea causes No H/O chest pain or breathlessness No H/O bleeding from nose or bleeding gums No H/O altered sleep pattern For cardiac causes Complications of liver dysfunction PAST HISTORY: No H/O similar complaints in the past No H/O diabetes, hypertension, tuberculosis, bronchial asthma or epilepsy. No H/O tattooing No H/O previous blood transfusions No H/O previous abdominal surgeries PERSONAL HISTORY: The patient is non-vegetarian Chronic smoker For the past 30 years Smokes 20 beedi/day(1 pack) Smoke years20X30600 Pack years1X3030 Dravergonz’13 Chronic alcoholic For the past 30 years Type: Brandy 180 ml per day 4 to 5 times a week No H/O drug abuse FAMILY HISTORY: No H/O similar complaints among family members SOCIOECONOMIC HISTORY: According to modified Kuppusamy scale, the patient belongs to CLASS 4(Upper lower socioeconomic class) SUMMARY: A 48 year old male, a chronic smoker and an alcoholic, came with complaints uniform abdominal distension and jaundice for the past 15 days. The system involved is hepatobiliary system. GENERAL EXAMINATION The patient is, Conscious Oriented Afebrile Moderately built and moderately nourished Anaemic Dravergonz’13 Jaundiced No cyanosis No clubbing Bilateral pitting Pedal oedema is present No significant generalised lymphadenopathy Markers: Markers of liver cell failure Jaundice Parotid enlargement are present Flapping tremor Ascites VITALS: PULSE: Rate: 84/minute Rhythm: regular Volume: normal volume Character: no specific character No radio femoral delay No vessel wall thickening Felt equally in all peripheries BLOOD PRESSURE: 130/90 mmHg Measured in the left upper limb with patient in supine position RESPIRATORY RATE: Rate: 26/minute Rhythm: regular Type: Thoraco-abdominal type Dravergonz’13 TEMPERATURE: 37° C JVP: not elevated EXAMINATION OF ABDOMEN INSPECTION: Oral cavity: Lips- normal Buccal mucosa- normal Tongue- normal Teeth- normal Gums- normal No halitosis Abdomen proper: Abdomen is uniformly distended Flanks full All the quadrants of the abdomen moves equally with respiration Umbilicus Shifted downwards Flushed to the surface Appears as a transverse slit No dilated veins or discoloration around the umbilicus No nodules Skin over the abdomen is stretched and shiny No dilated veins, scars or sinuses Dravergonz’13 No tapping marks No visible peristalsis Divarication of recti is present Hernial orifices- free External genitalia- normal Left Supraclavicular fossa- free PALPATION: Not warm Non-tender Liver is not palpable If liver is palpable, describe it as follows; Liver is palpable 8 cm from the right costal margin Tender/non-tender Smooth surface Firm in consistency Lower border is sharp Moves with respiration Insinuation not possible Spleen is palpable 6 cm from the left costal margin Tender Dravergonz’13 Smooth surface Moves with respiration Spleenic notch is felt Not ballotable and not bimanually palpable Insinuation not possible Measurements: Xiphisternum to Umbilicus Umbilicus to pubic symphysis Spino-umblical RIGHT distance LEFT Abdominal girth 22 12 15 15 98 No fluid thrill PERCUSSION: Liver span: 10 cm (Liver is shrunken) Spleen span: 8 cm (Spleen is enlarged) Shifting dullness is present AUSCULTATION: Normal bowel sounds heard No hepatic or Spleenic bruit No venous hum No hepatic or Spleenic rub Dravergonz’13 OTHER SYSTEM EXAMINATION: RS: Normal vesicular breath sounds heard A stony dull note if felt on the right Infraaxillary, lower Interscapular and infrascapular areas CVS: S1, S2 heard No added sounds No murmur CNS: No focal neurological deficit Flapping tremer is present No constructional apraxia(able to draw star) Reiter’s Number connection test- able to perform (Record this in case sheet) DIAGNOSIS: It is a case of Ascites with cirrhosis of liver in decompensated state with portal hypertension probably due to alcoholic aetiology without hepatic encephalopathy. Dravergonz’13 NOTES: CNS: If a patient presents with INABILITY in using his limbs, it is not necessary to elicit a detailed history regarding the motor system. Don’t forget to mention about carotid pulsations The power of the muscles differs for each movement. Record it carefully Power of a muscle for specific movement can be zero, but the power of the whole limb can never be zero(in chronic cases). Look for the tone carefully If the reflexes are brisk, look for CLONUS. RS: History of smoking, contact history, occupational history and socioeconomic history are important. General examination, start with whether the patient is comfortable or dyspnoeic at rest. CVS: Don’t forget to look for JVP Measure BP in all the 4 limbs In other system examination, look for cripitations ABDOMEN: Don’t forget to look for JVP History of alcohol intake should be in detail In other system examination, look for right sided pleural effusion, flapping tremer, constructional apraxia. Dravergonz’13 For each case write the investigation and treatment particular to that case only. Refer Mathew’s manual of medicine for investigation and treatment ALL THE BEST
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